Post-Traumatic Stress Disorder and Alcohol Use Disorder During the COVID-19 Outbreak: Do Dissociation and Emotional Metacognitive Beliefs Mediate the Role of Emotion Dysregulation?

The predictive role of emotion dysregulation

A potential explaining variable of both PTSD and alcohol use disorder is emotion dysregulation. Emotion dysregulation can be considered an umbrella construct that refers to the set of psychological processes and characteristics that describe a poor capacity to modulate the valence, duration, and intensity of own emotional states in order to behave successfully in coherence to own’s goals [39,40]. This construct is complex and multidimensional and is often considered as a transdiagnostic psychopathological factor [41,42]. The association between emotion dysregulation and both PTSD and addictions has been well established from a theoretical and empirical point of view [43-48]. Noteworthy, contributions published in the last decades stressed the importance to consider the way emotion dysregulation dimensions interact with contextual factors [49,50]. For instance, it has been argued that the adaptive versus maladaptive role of some emotion regulation strategies should be considered in light of the environmental demands [51,52]. Therefore, there is a need to investigate the role of emotion dysregulation in different contexts to extend the knowledge regarding the relationship between emotion dysregulation and psychopathology. Of note, few studies investigated the link between emotion dysregulation and both PTSD and alcohol use disorder in the context of the outbreak. Some authors found that heart rate reactivity to acute psychological stress predicts higher levels of PTSD symptoms during the COVID-19 pandemic [53] and others that emotion dysregulation predicted PTSD symptoms [8]. Also, among a sample of frontline healthcare workers, Zhou et al. [24] found that coping strategies mediated the relationship between perceived organizational support and PTSD symptoms. Regarding addictions, Cho et al. [54] observed that distress intolerance, anxiety sensitivity, and negative urgency predicted substance use among adolescents during the pandemic and that these pathways were mediated by the need to cope with outbreak related concerns.

Beyond the issues related to the topic of the COVID-19 outbreak, our knowledge regarding the mechanisms that may explain the association between emotion dysregulation and both PTSD and alcohol use disorder is far from being complete. For instance, the few studies that explored the topic of mediators linking emotion dysregulation to alcohol consumption highlight the role of metacognitions towards alcohol use [55], drinking motives [56,57], and depressive symptoms [58]. Other potential but currently overlooked variables accounting for the relationship between emotion dysregulation and both PTSD symptoms and alcohol use disorder are dissociation and emotion beliefs.

Mediators of the link between emotion dysregulation and both post-traumatic stress disorder and alcohol use disorder

Dissociation refers to a set of distinct processes related to the disaggregation psychological functions deputed to the maintenance of the integrity of consciousness. The definition of dissociation and dissociative experiences is still a matter of debate and includes the question of its conceptualization as laying on a continuum ranging from normality to pathology [17]. The acceptation of the construct as a pathological process helped to recognize different dissociative experiences that characterize several mental disorders as such as borderline personality disorder, dissociative disorders, and PTSD [18]. The construct of dissociation refers to several features as such as altered experiences of consciousness called derealization and depersonalization (i.e., feeling to be outside of own body or feeling far away from the reality), amnesia (i.e., not remembering actions or events), and absorption (i.e., an intense experience of immersion in an activity together with a loss of psychological contact with the external world).

The explanations of why an individual may be more prone to dissociate compared to others include the role of emotional experiences [59]. Indeed, it has been argued that individuals dissociate more likely when they experience strong and negative emotional states [60]. From this perspective, it has been stated that a poor capacity to regulate own emotions may act as a predictor of the proneness to dissociate [61]. Importantly, dissociation is also thought to be strongly associated with PTSD [18]. Specifically, an individual experiencing high levels of fear, for instance when exposed to a traumatic event, may respond activating dissociative processes in order to transitory protect own psychological functioning. Therefore, a proneness to dissociate has been shown to act as a risk factor for the onset of PTSD [62]. High levels of dissociation have been showed to increase the risk for developing an addiction too [31]. Indeed, dissociation is likely to undermine self-regulation in consumption behavior, fostering the development of mechanisms accounting for addictions. As a whole, several preliminary evidences suggest that dissociation may be a central variable that mediates the relationships between emotion dysregulation and both PTSD and alcohol use disorder.

Another potential mediator of these relationships is metacognitions towards emotions. These correspond to the beliefs an individual has towards the utility and controllability of emotional states (either positive or negative). Past research demonstrated that emotion regulation self-efficacy is strongly related to emotion regulation capacities [63]. Therefore, believing that emotional states are not malleable and are out of control is likely to be associated with emotion dysregulation [64]. Similarly, negative beliefs towards emotions consisting in viewing emotional states as usefulness are likely to be associated with emotion dysregulation and especially with the lack of emotional awareness and emotional clarity. Despite the construct of emotional belief deserved a growing attention from researchers in the last decades, the opportunity to investigate the role of this topic has been only recently offered to the scientific community with the creation of the Emotional Belief Questionnaire (EBQ [65]). Therefore, direct empirical evidences regarding the link between this set of variables and some psychopathological conditions have been not extensively produced. However, a wide number of studies reported the relationship between the tendency to judge negatively own emotion states and PTSD or addictions [8,66]. Despite the current lack of evidence surrounding this issue, the gap regarding the exploration of the relationships between metacognitive beliefs and psychopathological outcomes (as such as PTSD and alcohol use disorder) and the potential mediating role of this variable in the pathways linking emotion dysregulation and psychopathological conditions is still to bridge.

The present study

As a whole, the existing literature suffers from several limitations. First, few studies investigated the relationship between emotion dysregulation and both PTSD and alcohol use disorder in the context of the outbreak. Then, the knowledge concerning the potential mediators accounting for these relationships is still limited. Specifically, dissociation and emotional beliefs are likely to explain these pathways, but few empirical evidences documented these topics. Therefore, a cross-sectional study on a sample of community participants was conducted to test the following hypotheses: H1. Emotion dysregulation will be associated with both PTSD and alcohol use disorder in the context of the COVID-19 outbreak. H2. Emotion dysregulation will be associated with both dissociation and emotional beliefs. H3. Dissociation and emotional beliefs will mediate the relationships between emotion dysregulation and both PTSD symptoms and alcohol use disorder.

Participants and procedure

In this study, a sample of 719 Italian adults has been recruited throughout a convenience sampling technique method (32.5% males; M_age=34.36, standard deviation [SD]=14.38 years). The only inclusion criteria were to being 18 years or older, to live in Italy and to have a sufficient understanding of the written Italian language. Specifically, an URL redirecting on a survey created on the EUsurvey platform was send to all potential participants. Starting the survey implied first to confirm being older than 18 years and read a cover letter illustrating the aims and the procedure of the study as well as information regarding anonymity and privacy. The main goal of the study, investigating the psychological impacts of the COVID-19 pandemic was illustrated in this cover letter. The email contact of the responsible for treatment data was also provided in order to allow the request of additional information regarding these issues. Finally, in case participants accepted to participate to the study, they were asked to fulfill an informed consent. Afterward, participants were asked to complete a battery of self-report questionnaires.

Instruments

An initial questionnaire, created for the purposes of the study, collected demographic data as such as age and sex.

To measure emotion dysregulation levels, the Italian version of the Difficulties in Emotion Regulation Scale Short Form [39,67] was administrated. This questionnaire consists of 18 items asking the individual to answer on a 5-points Likert type scale (1=never; to 5=always) and provides a total score as well as a score for each subscales measuring distinct emotion dysregulation dimensions corresponding to 1) impulse-control difficulties, 2) difficulties pursuing goal-directed behavior when experiencing an negative emotions, 3) poor emotional awareness, 4) poor emotional clarity, 5) poor capacity to access to effective emotion-regulation strategies, 6) difficulty to accept in a nonjudgmental way own negative emotions. Overall, the instrument confirmed its good reliability as showed by the Cronbach’s values being 0.89 for the total score and higher than 0.74 for all subscales expect for the awareness subscale that obtained a reliability coefficient of 0.65.

Metacognitive beliefs regarding emotional responses were measured thanks to the administration of the EBQ [65]. This is a 16 items self-report questionnaire asking the participant to answer on a 7-points Likert type scale ranging from 1 (strongly disagree) to 7 (strongly agree). Different scoring methods have been provided by the authors that lead to the identification of specific subscales. For the purpose of this study, the subscales Positive Usefulness, Negative Usefulness (i.e., corresponding to beliefs regarding the lack of utility of positive and negative emotions respectively) and Controllability (i.e., beliefs about how emotions are uncontrollable) have been used. Preliminary analyses supported the good internal consistency of the EBQ subscales with Cronbach’s alpha resulting ≥0.81.

To measure dissociation levels, the Italian translation of the second version of the Dissociative Experiences Scale (DES [68,69]) has been administrated to all participants. This self-report questionnaire, consisting of 28 items with an answer response scale ranging from 0 (0% of the time) to 10 (100% of the time), evaluates the frequency by which the individual experience dissociative experiences in daily life. Because the factorial structures of the instrument are still a matter of debate [70], a conservative approach has been selected, using the original three factorial structure of the instrument. Therefore, three subscales have been used corresponding to three subtypes of dissociative experiences being depersonalization/derealization (DD, i.e., altered perceptions of the self or the surroundings), absorption (i.e., immersion in activities and unawareness of the external environment), and amnesia (i.e., not remembering past actions or events). Each subscale of the instrument showed, in this study, an excellent internal reliability with Cronbach’s alpha not being lower than 0.86.

Alcohol use disorder was measured with the Alcohol Use Disorders Identification Test (AUDIT [71]) that is a self-report questionnaire encompassing 10 items investigating the frequency of alcohol-related behaviors. The Cronbach alpha index obtained in this study (0.74) supported the good internal consistency of the instrument.

Finally, to measure the levels of PTSD symptoms, a modified version of the National Stressful Events Survey PTSD Short Scale [72] has been administered. This instrument asks the participant to answer to each of its 9 items on a 5-points Likert-type scale ranging from 0 (not at all) to 4 (extremely). In the version used in the study, we specified in the instruction that participant should have answered referring only to stressful events related to the COVID-19 outbreak. In this study, the instrument showed a good internal consistency with a Cronbach’s alpha index being 0.89.

Ethical approval

The researcher procedure received the approval of the Ethical Committee of the University of Rome Sapienza Ethical Board (N° 808/2020) and were developed in compliance with the guidelines of the American Psychological Association for ethic in research. The study was conducted according to the ethical approval protocol and the 1975 Helsinki Declaration. Informed consent was signed by all the participant.

Statistical analyses

Analyses were performed by several steps. In a preliminary step, the internal consistencies of the measures used in the study have been verified calculating alpha Cronbach’s indexes. Afterward, using age and sex as covariates, the r-Pearson correlation matrix estimating the association between the main variables included in the study was calculated. These preliminary analyses were performed using the SPSS software v.23 for Windows (IBM Co., Armonk, NY, USA). The last step of the analytical plan was instead carried out using the lavaan package of the Rstudio software for Mac (R Foundation for Statistical Computing, Vienna, Austria). This consisted in the creation and the test of a structural equation model. Specifically, the model has been tested using the maximum likelihood estimation method and the goodness of fit was evaluated using several fit indexes namely the comparative fit index (CFI) and the root mean square error of approximation (RMSEA) [73,74]. Acceptable fit was considered when the indexes were equal or superior to 0.90 and inferior or equal to 0.08 for CFI and RMSEA respectively. In addition, in case of poor fit, modification indexes of the software were used in order to better specify the model adding the estimation of the correlation of some residuals [75,76].

Descriptive analyses

Regarding the demographic characteristics of the sample, 98.3% of participants reported to be Italian and 24.2% stated to have at least one child. 17.4% of participants lived with the partner and/or with own child(ren) whereas most (47.4%) lived alone or with parents (13.1%). Fourteen participants were currently under quarantine measure while fulfilling the survey. Most participants lived in the Latium (56.9%), a central area of Italy and the others were quite well distributed across the Italian territory with a high percentage of participants also living in Lombardy (7.5%) the Italian area facing the highest rate of COVID-19 contaminations. Analyses of frequency were performed regarding potential traumatic variables related to the COVID-19 pandemic. In the total sample, four participants stated having been contaminated by the COVID-19 pandemic and one of them having been hospitalized. Also, 63 stated that they know at least one significant other (i.e., family member, friend or colleague) being contaminated by the COVID-19 and 25 participants reported having lost at least one significant other because of the COVID-19. Lastly, 58 participants stated that they changed or lost their job because of the COVID-19 pandemic. In addition, means and SDs of each variable involved in the study were calculated (see Table 1).

Table 1.

Ranges, means, and SDs of continuous variables involved in the study

Partial correlations between main variables involved in the study

Computations of partial r-Pearson correlations matrix, controlling by age and sex, evidenced some statistically significant associations between the main variables investigated in the study. A full overview of results is available in Table 2. It was found that PTSD levels correlated positively and significantly with all other variables and that AUDIT total scores correlated positively and significantly with PTSD scores, emotion dysregulation levels, the uncontrollability, and positive usefulness subscales of the EBQ and the DD subscales of the DES-II. Also, the DERS-SF total score, the EBQ and DES-II subscales correlated significantly and positively with each other except for the Absorption subscale of the DES-II that was not correlated significantly with the EBQ subscales measuring usefulness beliefs towards positive and negative emotions.

Table 2.

Partial correlations, controlling for age and sex, between PTSD, alcohol disorder, emotion dysregulation, emotional beliefs, and dissociation

Structural equation model

The measurement model was drawn using items or subscales of each measure to create five latent variables (LVs). When instruments provided subscales, these were preferred to single items in order to avoid an overparameterization of the model. Specifically, the nine items of the National Stressful Events Survey PTSD Short Scale, the 10 items of the AUDIT, the six subscales of the DERS, the three subscales of the DES-II, and the three subscales of the EBQ were used as manifest variables to create the PTSD, alcohol use disorder, the emotion dysregulation, the dissociation and the emotion beliefs LVs, respectively.

Regarding the path model, this was created coherently with the hypotheses of the study. Specifically, emotion dysregulation was inserted as a predictor of all other LVs whereas dissociation and emotional beliefs were inserted as predictors of both PTSD and alcohol use disorder LVs. In addition, the indirect pathways leading emotion dysregulation to both PTSD and alcohol use disorder throughout the parallel mediating role of both emotional beliefs and dissociation levels were estimated. Finally, age and sex were inserted as covariates predicting the two outcomes (i.e., PTSD and alcohol use disorder).

The first test of the model obtained a good fit considering the RSMEA index (0.06; confidence interval [CI] 90%, 0.055 to 0.062). However, the CFI felt below the acceptable cut-off (0.88). Therefore, following the modification indexes, additional parameters were added to the model until a satisfactory fit was obtained according to both indexes. Four parameters, concerning the correlations between residuals of manifest variables converging on the same LVs, were added. The final model, fully displayed in Figure 1, showed a good fit with an RMSEA index being 0.05 (CI 90%, 0.050 to 0.057) and a CFI reaching 0.90. Regarding the measurement model, manifest variables significantly and positively loaded on the expected LVs. Results related to the path model evidenced that both emotional beliefs and dissociation were positively and significantly predicted by emotion dysregulation levels. Multiple regressions investigating the factors predicting PTSD levels identified emotion dysregulation, dissociation, and sex as positive and significant predictor whereas emotional beliefs and age did not explain an additional portion of observed variance. In addition, all variables, except emotion dysregulation, were showed to significantly predict alcohol use disorder levels either positively (dissociation, emotional beliefs) or negatively (age, sex). Regarding the indirect pathways, results indicated that dissociation significantly mediated the relationship between emotion dysregulation and PTSD levels (b=0.14, p<0.001) whereas emotional belief did not (b=0.01, p=0.651). Finally, data evidenced that the relationship between emotion dysregulation and alcohol use disorder was mediated by both dissociation (b=0.11, p=0.002) and emotional beliefs (b=0.05, p=0.036).

Figure 1.

Structural equation model testing the mediating role of emotional beliefs and dissociation in the relationships between emotion dysregulation and both PTSD symptoms and alcohol disorder. Dashed lines indicate non-significant paths; solid lines indicate significant paths at a 0.05 level; covariance alcohol disorder and PTSD=-0.002 (p=0.753). PTSD, post-traumatic stress disorder; DD, depersonalization/derealization.

Limitations and future directions

The conclusions drawn from the present study should be appreciated keeping in mind some key limitations. First, the design of research used is likely to limit the inferences that can be made towards the causal nature of the relationship observed. Therefore, an additional study may want to replicate the results obtained throughout the conduction of a longitudinal or experimental study. Also, participants were recruited among community and no clinical sample was included in the study. This may be especially problematic in light of the generalization of the conclusions to the clinical population. Again, a future study may want to replicate the study suing a sample of individuals suffering from PTSD and/or alcohol use disorder. Finally, the operationalization of the emotion dysregulation construct did not include the role of positive emotions. For instance, inspiring past studies used instrument as such as the Difficulties in Emotion Regulation Scale Positive or measuring the construct of Positive Urgency [85]. Considering the result documenting the link between emotional beliefs on positive emotions and both PTSD and alcohol use disorder, this topic would have deserved a greater attention during the study planification. Therefore, future studies may want to extend the knowledge regarding this issue using specific measures that operationalize the construct of dysregulation of positive emotions.